AMA Expands Scope Campaign Against CAM Fields, Others; Nurses Blast "Medical McCarthyism"

Summary: At the November Interim Meeting of the AMA House of Delegates, delegates considered two resolutions expanding the reach of the AMA Scope of Practice Partnership. One related to "oversight of mid-level providers" and the other regarded interpretation of diagnostic tests. The American Association of Nurse Anesthetists says AMA action "smacks of McCarthyism." AMA, which has not had nine distinct resolutions on SOPP issues, has placed the SOPP in its strategic plan.

The list of targets of the American Medical Association's Scope of Practice Partnership  appears to have grown with action proposed for the November 2006 AMA House of Delegates Meeting. (See list of prior Integrator articles on the topic, below.)

• Resolution 902 (see full language below) asserts that it will be AMA policy "that state medical boards shall have full authority to regulate the practice of medicine by all persons within a state notwithstanding claims to the contrary by boards of nursing, mid-level practitioners or other entities." The AMA will seek to find licensing board members in each state who will seek to actively prosecute others. Introduced by the American Society of Anesthesiologists.
  

• Resolution 904 (see full language below) clarified that "the diagnosis of disease and diagnostic interpretation of a study or studies for a specific patient constitutes the practice of medicine." One target is expansion of scope by PhD researchers. The AMA will work to insure that Medicare fee schedules do not reimburse independent practices. Introduced by the College of American Pathologists and the American Society of Anesthesiologists.

Prior to the meeting of the House, the American Association of Nurse Anesthetists (AANA), a 36,000 member group, filed lengthy comments urging the House to not pass either of the two Resolutions. The AANA points to the lack of hard data behind the AMA SOPP assertions of harm caused by non MD/DO practitioners, charging that the AMA effort "smack of McCarthyism."

"[Resolution 902] states that 'some' 'mid-level or limited license practitioners' continue to 'attempt to practice medicine' and 'rely on false assertions of authority, not backed up by scope of practice laws, by various nursing boards and other bodies regulating limited license practitioners ….'

"How many practitioners constitute 'some' practitioners?  Two?  A dozen?  Five hundred?  How are such practitioners 'attempting' to practice medicine?  What are the so-called 'false assertions' of authority by various regulatory boards to which the resolution is referring?  These sweeping statements, unsupported by evidence, smack of McCarthyism  -- arousing fears to instigate a witch hunt despite the lack of substantial evidence justifying the action.  [Bold added.] In fact, when no evidence exists to support a claim, accusers often use broad, sweeping claims that force the accused to discredit the claims even though there is no evidence to support the claim in the first place.  We assume the AMA does not want to be known for making policy based on witch-hunt logic or McCarthyistic tactics."

"Scope of Practice                 

"Our AMA will take a lead role in coordinating medicine’s response to proposed scope expansions that are not warranted by non-physicians’ education, training or experience.  The Scope of Practice Partnership (SOPP) provides a foundation for these activities.

"As we gain experience and traction with the SOPP, we anticipate formation of rapid response coalitions that cross specialty groups.  We will consider creation of state-level joint review committees, supported in part by a compendium comparing education, licensure, etc. for different types of practitioners.  We will also seek data to map the geographic distribution of various practitioner types in order to inform discussion of access to care."

Imaging the AMA SOPP campaign ...

AMA House of Delegates Resolution 902 

Need for Active Medical Board Oversight
of Medical Scope-of-Practice Activities by Mid Level Practitioners

Introduced by:           American Society of Anesthesiologists 

Referred to:               Reference Committee L
                               (H. David Bruton, MD, Chair)

Whereas, Quality medical care requires appropriate education, skills, training and experience, as recognized and established by state laws; and

Whereas, As physicians, Medical Doctors (MDs) and Doctors of Osteopathy (DOs) are the only persons fully licensed by the states to practice medicine; and

Whereas, Some mid-level or limited license practitioners continue to attempt to practice medicine and rely on false assertions of authority, not backed up by scope of practice laws, by various nursing boards and other bodies regulating limited license practitioners; and

Whereas, The quality of care rendered by individuals with limited licenses is not equivalent to that of a physician (MD or DO); and

Whereas, Patients may be put at risk for injury or death by receiving care from persons who are not physicians (MD or DO), but who claim to be able to render medical care under the pretense that such conduct is allowed by their respective state board or similar entity; and

Whereas, State-based regulation and licensure of medicine should be aggressively protected to ensure patient safety and optimal clinical outcomes; and

Whereas, Some state medical boards have asserted that they lack jurisdiction over limited license practitioners who claim to act under the authority of boards or entities other than the state medical board, even though the conduct of such limited license practitioners would otherwise amount to the practice of medicine without a license; and

Whereas, The Federation of State Medical Boards (FSMB) established the Special Committee on Scope of Practice in July 2003, charged with making decisions about changes in scope of practice for non-physician practitioners, but it has declined to assist in prosecuting cases of medical practice by limited license practitioners operating under claims of authority by limited license boards and similar entities; and

Whereas, A unified response by organized medicine is needed to counter the inability or unwillingness of state medical boards and the FSMB to halt the unlicensed practice of medicine; and

Whereas, Our AMA and the Scope of Practice Partnership are uniquely positioned and well qualified to address this matter of extreme urgency so that our state laws and regulations can be upheld and the authority of state medical boards can be re-established as having full jurisdiction, oversight and authority over medical scope-of-practice activities by mid-level practitioners; therefore be it

RESOLVED, That it shall be the policy of our American Medical Association that state medical boards shall have full authority to regulate the practice of medicine by all persons within a state notwithstanding claims to the contrary by boards of nursing, mid-level practitioners or other entities (New HOD Policy); and be it further

RESOLVED, That our AMA, through the Scope of Practice Partnership, work jointly with state medical boards to assist law enforcement authorities in the prosecution of unlicensed medical practice by limited or mid-level practitioners (Directive to Take Action); and be it further

RESOLVED, That our AMA, through the Scope of Practice Partnership, immediately embark on a campaign to identify and have elected or appointed to state medical boards physicians (MDs or DOs) who are committed to asserting and exercising their full authority to regulate the practice of medicine by all persons within a state notwithstanding efforts by boards of nursing or other entities that seek to unilaterally redefine their scope of practice into areas that are true medical practice. (Directive to Take Action)

Fiscal Note: Implement accordingly at estimated staff cost of $10,836.

AMA House of Delegates Resolution 904 - Received 9/25/06

Diagnosis of Disease and Diagnostic Interpretation of Tests
Constitutes Practice of Medicine to be Performed by or Under
the Supervision of Licensed Physicians

Introduced by:         College of American Pathologists
                             American Society of Anesthesiologists       

Referred to:             Reference Committee L
     (H. David Bruton, MD, Chair)

Whereas, There is a growing trend of non-physician personnel seeking to expand their scopes of work into functions that traditionally constitute the practice of medicine; and

Whereas, The diagnosis of disease constitutes the practice of medicine and requires the integration of the interpretation of a study or studies with clinical experience and training; and

Whereas, Laboratory personnel, including PhD scientists, are increasingly involved in the implementation of new laboratory technologies that require specialized training and education to perform such study or studies, but such training and education does not induct the ability to make a diagnostic interpretation for a specific patient; and

Whereas, Specialty societies representing non-physician laboratory personnel and PhD scientists are advocating for expansion of their scope of work into independent practice in the clinical setting and recognition through payment under the physician fee schedule; and

Whereas, Our AMA has long recognized that quality medical care requires appropriate education, skills, training and experience, as recognized and upheld in state laws; and

Whereas, AMA Policy H-35.988 furthers the public interest in quality medical care by opposing enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state's requirements for licensure to engage in the practice of medicine and surgery in all of its branches; and

Whereas, AMA Policy H-35.973 supports the formulation of clearer definitions of the scope of practice of physician extenders to include direct appropriate physician supervision and recommended guidelines for physician supervision to ensure quality patient care; and

Whereas, AMA Policy H-35.993 opposes any legislation or program that would provide for Medicare payments directly to physician extenders, or payment for physician extender services not provided under the supervision and direction of a physician; therefore be it

RESOLVED, That it shall be the policy of our American Medical Association that the diagnosis of disease and diagnostic interpretation of a study or studies for a specific patient constitutes the practice of medicine (New HOD Policy); and be it further

RESOLVED, That it shall be the policy of our AMA that a PhD scientist or other non-physician laboratory personnel work under the supervision or in collaboration with a physician under their applicable scopes of work to perform a study or studies that will be the basis of a diagnostic interpretation for a specific patient (New HOD Policy); and be it further

RESOLVED, That it shall be the policy of our AMA that the Medicare physician fee schedule compensate only authorized persons for the diagnostic interpretation of a specific patient and should not provide payments directly to non-physician personnel working under the supervision or in collaboration of a physician to perform a laboratory study or studies (New HOD Policy); and be it further

RESOLVED, That our AMA pursue all appropriate legislative, regulatory and legal actions through the Scope of Practice Partnership to counter expansions of the scope of work by PhD scientists and other non-physician laboratory personnel to authorize the independent practice of medicine by any individual who has not completed the state's requirements for licensure to engage in the practice of medicine. (Directive to Take Action)

Fiscal Note: Implement accordingly at estimated staff cost of $1,929.

Received: 9/25/06

RELEVANT AMA POLICY

H-35.973 Scopes of Practice of Physician Extenders

Our AMA supports the formulation of clearer definitions of the scope of practice of physician extenders to include direct appropriate physician supervision and recommended guidelines for physician supervision to ensure quality patient care. (Res. 213, A-02)

H-35.988 Independent Practice of Medicine by "Nurse Practitioners"

The AMA, in the public interest, opposes enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state's requirements for licensure to engage in the practice of medicine and surgery in all of its branches. (Sub. Res. 53, I-82; Reaffirmed: A-84; Reaffirmed: CLRPD Rep. A, I-92; Reaffirmed: BOT Rep. 28, A-03)

H-35.993 Opposition to Direct Medicare Payments for Physician Extenders

Our AMA reaffirms its opposition to any legislation or program which would provide for Medicare payments directly to physician extenders, or payment for physician extender services not provided under the supervision and direction of a physician. (CMS Rep. N, I-77; Reaffirmed: CLRPD Rep. C, A-89; Reaffirmed: Sunset Report, A-00)

D-35.990 Limiting the Scope of Practice of Specialist Assistants in Radiology

Our AMA supports the efforts of the American College of Radiology and will work with the Scope of Practice Partnership and interested Federation partners to obtain regulation or legislation which would preclude a Specialist Assistant in Radiology or other non-physician practitioner from rendering an official report of any image produced by any diagnostic imaging technique. (Res. 219, A-06)

D-35.991 Licensure of Naturopaths

Our AMA will work through the Scope of Practice Partnership and interested Federation partners to oppose the licensure of naturopaths and report back to the House of Delegates at the 2006 Interim Meeting. (Res. 209, A-06)

D-35.992 Need to Expose and Counter Nurse Doctoral Programs (NDP) Misrepresentation

Our AMA will: (1) work jointly with state attorneys general to identify and prosecute those individuals who misrepresent themselves as physicians to their patients and mislead program applicants as to their future scope of practice; (2) pursue all other appropriate legislative, regulatory and legal actions through the Scope of Practice Partnership, as well as actions within hospital staff organizations, to counter misrepresentation by nurse doctoral programs and their students and graduates, particularly in clinical settings; and (3) work with all appropriate entities to ensure that all persons engaged in patient contact be clearly identified either verbally, or by name badge or similar identifier, with regard to their professional licensure in order that patients are aware of the professional educational background of that person. (Res. 211, A-06)

D-35.999 Non Physicians’ Expanded Scope of Practice (Laboratory Testing and Test Interpretation)

Our AMA, through appropriate legislative and regulatory efforts, seeks to: (1) ensure that diagnostic laboratory testing should only be performed by those individuals who possess appropriate clinical education and training, under the supervision of licensed physicians (MD/DO); and (2) limit laboratory test ordering and interpretation of test results solely to licensed physicians (MD/DO) and licensed dentists (DDS/DMD). (Sub. Res. 307, A-00)